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Wednesday, September 26 2012

Neuroscientific Mirages: Are We No More Than Our Brains?

In the middle ages, scholars often began their debates and expositions with the formula: videtur quod non,meaning, “it would appear that such and such is not true.” Thus, the scholars defended their thesis in 2 steps.

First, the discussions centered on the considerations that made the thesis seemingly unlikely. Subsequently, the scholars argued that these considerations were not valid.

Here we will follow the reverse path: videtur quod sic, meaning, “it seems that such and such is true,” to subsequently show that actually it is untrue.

The issue at stake: It appears that in psychiatry, soul and mind have to retreat in favor of the brain and that brain sciences will soon occupy center stage, if that is not already the case.

Here we argue that this prediction is insufficiently grounded, and that if it should happen, the damage to psychiatry would be considerable.

Some definitions first

To begin with, briefly, the definitions of the concepts involved. The word “soul” (or psyche) is used as a metaphor for the conglomerate of psychic functions that enable man to be cognizant of both the world around him and his inner world, to make contact with fellow men, and to interpret that information both intellectually and emotionally.

The word “mind” is used to indicate those ingredients of the soul that make each individual into a unique self. It pertains to the internal structure of the self: the cognitive style of an individual, his ability to analyze, to conceptualize, and the depth and variegation of his emotional repertoire. Mind refers to his aspirations, hopes, and disappointments, his ability to love and to make moral judgments, the measure of his self-consciousness, etc. Mind also encompasses man’s urge to achieve purpose and meaning as well as his desire to provide life with a vertical dimension, to once in a while reach out beyond the horizon—where the lands lie of our dreams, our imagination, and the metaphysical experiences—and where religious sensitivity finds its birthplace.

Mind makes man identifiable for himself and others. Mind is the very essence of selfhood. It overshadows the bodily characteristics of the self by far. Phrased parsimoniously: the soul provides the basic tools with which the unique edifice of the mind is constructed.

Did Descartes err?

The relationship between body and soul has been debated by philosophers for thousands of years. Descartes is linked to the notion that a sharp distinction should be made between body and mind. The body—the res extensa—has spatial extensiveness; the mind—the res cogitans—on the other hand, does not. Both “substances” were thought to operate independently, apart from a possible hyphen Descartes hypothetically located in the pineal gland. The body could be studied with mechanical tools, like a machine; the mind could not, was a domain for philosophical studies.

Descartes has often been misunderstood, taken for a rigorous dualist. For instance, Damasio1 wrote: “Descartes imagined thinking an activity quite separate from the body.” Damasio erred. Descartes considered features such as “feelings” and “tendencies” body- (ie, brain-) dependent. The mind was not, could not be, because it was considered to be immortal. In his day and age, this viewpoint could hardly be (openly) questioned.

Dualism, the separation of brain and mind, is not a popular viewpoint in neurobiological circles, including among biologically oriented psychiatrists. Kendler2 wrote: “Cartesian dualism is false. We need to reject definitively the belief that mind and brain reflect two fundamentally different and ultimately incommensurable kind[s] of ‘stuff.’” He expressed himself rather moderately.

Others have been more outspoken. Swaab3 stated: “We are our brains. The mind I see as a product of our brain cells. Mind is simply material, or better, brain and mind are one thing.” Kandel4 wrote: “What we call mind is a range of functions carried out by the brain.” And, Guze5 declared: “One’s feelings and thoughts are as biological as one’s blood pressure and gastric secretion are.”

Neuronal determinism, as this worldview is called, reigns supreme today. Many neuroscientists, including their psychiatric adherents, believe that by means of brain research, the code of mind and selfhood will be cracked. They consider the problem-solving power of the sciences—the natural sciences—principally boundless. To me this sounds like scientific messianism.

The appearances, however, seem to be against me: videtur quod sic. Scan technology, for instance, brought functional and morphological brain defects to light in a variety of psychiatric disorders. Most evidence suggests that these disturbances underlie the behavioral aberrations, rather than being their consequence. Functional brain changes enable us to execute those functions.

Brain damage, more often than not, leads to behavioral and experiential changes. Drugs may influence brain functions and have the potential to exert both beneficial and detrimental effects on the behavioral repertoire. Chronic biological strain damages the brain and may lead to mental disturbances. Even religiousness, the most esoteric of the mind’s ingredients, seems to be neuronally anchored.6

Mind is a brain derivative and mental disorders are essentially disorders of the brain, and their causal treatment is a matter of brain repair. So it seems. Yet, I reject this reasoning categorically. I submit that dualism, neodualism should be “in” and should remain the very foundation of psychiatry, in both its clinical and therapeutic endeavors. With the term “neodualism,” I allude to the notion that body-brain and mind, although interdependent, can each boast a considerable amount of internal autonomy.

Furthermore, I maintain that mind and brain are made of fundamentally different “stuff”; that mind “stuff” should be systematically studied in its own right, with specific methods not comparable to the ones used by neurobiologists; and that mind “stuff” cannot and will never be fully extrapolatable to brain “stuff.” As an analogy: electric currents can be generated by a generator. Generator and current are coupled, yet they are phenomena of a totally different order, to be studied with different methods. Neither can the beauty, the color, the smell of a rose be extrapolated to the soil from which it springs.

We are our brains

This is the title of a book recently published by the neurobiologist Swaab.7 The wording sounds terse but misses the point. It holds water in that without the brain we wouldn’t be. This logic falters because our spiritual luggage is left unattended. We are more than a machine. Immaterial components are part of our being—our essential parts. They are lost in the phrase “we are our brains.” Brain knowledge yields pitifully little mind knowledge.

Suppose we had detailed knowledge of the neuronal substrate of aesthetic experiences, would that explain their origin, character, and salience in a given individual, and his or her personal preferences? Suppose the neuronal underpinnings of religiosity became an open book, would that make us wiser about the origin of the spiritual needs, about the significance the “vertical dimension” has in someone’s life? Suppose the neuronal substrate of what is called intelligence had been fully clarified, would that knowledge reveal the ways those abilities were actually used? for what purpose? on which grounds? whether intellectual faculties have been used to the fullest, whether intellectual development has been detrimental to one’s emotional life. Does brain knowledge bring us any closer to understanding a person’s hopes, expectations, disappointments, sorrow, bliss, or shame? his love life and the way he loves? Does it provide information about his ability to make moral judgments?

The answer to these questions can hardly be in the affirmative. It is true, the mind’s existence depends on the existence of a brain. But it is also true that the mind has a life of its own, impenetrable to brain researchers, at least for the foreseeable future. The mind is in many respects an independently operating “product” of the brain. It is a domain with its own rules, its own provisions, to be studied with specific methods—methods that have nothing to do with biology. If the mind becomes a vassal territory of the brain sciences, science would suffer irreparably.

Oscar Wilde characterized a cynic as someone who knows the price of every thing but nothing of its value. If “knows” is replaced by “wants to know,” this definition fits the neural determinist perfectly.

Psychiatry is particularly endangered by this extreme variant of biological monism. The brain is dear to the psychiatrist; the mind no less. He has to deal with both—every day and with every patient. What is wrong in the brain? What is the matter with the mind? He ascertains that mental disturbances, more often than not, are preceded by perturbations of the mind. He knows that mind perturbations may cause brain perturbations. The study of the mind is therefore essential to diagnose and treat mental disorders properly. By definition, the psychiatrist is an examiner and healer of the brain as well as of the mind. If a car engine is malfunctioning because of long-term exposure to bad roads, both the engine and road need to be repaired. If they are not, engine problems will return.

Life is determined by the brain

The neuropsychologist Wolters8 called free will an illusion: “Neural determinism will take its place: What we experience, what we think and what we do, is fully determined by the actual state of the brain.” This, too, is a half-truth. The fact that we experience, think, and act is indeed completely determined by the brain. What we experience, think, and do—all of which are in large measure determined by us—is not our selfhood. That self is shaped by life experiences, the milieu in which one is raised, and regular introspection.

The brain provides no information on the way these factors shape the individual. Psychic individuation is not primarily determined by the brain, it is determined by selfhood—by the one I’m going to be and ultimately will be. Selfhood creates itself. It is the master builder of the mind. It is both product and producer. Such is the enigmatic character of who we are. Selfhood’s “fabric” is nebulous and elusive, yet it is experienced as concrete and real.

In the brain, selfhood is not recoverable. It is approachable only for soul researchers and soul healers, and that only to a limited extent. For neurobiologists, it is an entity like the Holy Grail: fascinating but untraceable, for the time being—and I presume, forever.

This is not a novel idea. In the first verses of the book of Genesis, God “formed man of the dust of the ground.” It was not before He breathed in man’s nostrils “the breath of life” that man became a person.9 Man’s mind was created by unique “mind-stuff.” Stuff that made man into more than a thing, it made him into an individual.

Man conceived as a machine is an obvious half-truth. A machine indeed, but a most peculiar one, a spirited machine. For some, a statement beyond belief. For others, like me, a truth. A mystery of the same magnitude as when, long ago, dead matter was converted into living matter, able to reproduce. In principle, mysteries are solvable. The ones I mentioned, however, are more mysterium magnum, ie, a mystery that will remain a mystery, for the time being and probably forever. It is more a romantic than a scientific idea. But, frankly, life without mysteries, in which everything is explicable and without wonders, would lose its luster. At least for me.

Man is the measure of all things

This ancient statement that “man is the measure of all things” was made by the Greek philosopher Protagoras. It is cited with applause by advocates of the “brain-only” idea. For me, this statement raises 3 objections.

1. Protagoras’s thesis has been unduly stretched. Protagoras probably meant to express that all human judgments are subjective, including those regarding abstractions such as righteousness, beauty, virtue, and values such as good and evil. Absolute truth does not exist. Every human being is entitled to make his own decisions.

Protagoras said: “As things occur to me, so they are for me; on the other hand, as things occur to you so they are for you.” In conformity with this reasoning he confessed to be an agnostic: “As far as the gods are concerned, I couldn’t say whether they exist or do not exist, or what their shape is, because many factors limit our knowledge as to that: the obscurity of the subject and the limitations of the human existence.” Protagoras was a relativist: man judges for himself and is his own chief justice. There exists no higher authority—man himself is the measure of all things.

“Brain-only” adherents link in to Protagoras’s relativism but give it another turn. Not so much man, since the brain is considered to be the measure of all things. Man is reduced to a strictly material entity. All his characteristics are materially determined, reducible to matter and hence measurable, given the availability of suitable devices. This holds for the whole of man, both his physical and spiritual features, ie, his mind.

“We are our brains.” The brain determines what and who we are. Beyond the brain lies nothingness. The brain is all-mighty and omnipotent. It is the ultimate contraption steering our life. The brain assumes almost divine grace—Protagoras’s thesis is excessively stretched; overstretched, I would say.

2. Protagoras phrased his thesis in such general terms that it is hard to interpret. He speaks of “man . . . ,” but which man? The average one (if that type exists), the exceptional man, the man approaching stupidity, the humane man or his egocentric counterpart? The variability of mankind is enormous. Furthermore, how do we “measure” man? Where does the benchmark go: in the middle, higher, or maybe lower?

Protagoras speaks of “all things.” But, what are these things? Morality perhaps? Taking into account man’s track record, this bespeaks a rather gloomy worldview. Is Protagoras speaking of introspection, reflection, empathy? The word “thing” is indefinite and, hence, meaningless. Thus, there are many questions but no answers.

3. The third objection is one of personal character. The statement that man is the touchstone of all things kindles in me dreary feelings. Is that arbitrary, undefined “man” really our gauge? Should the standard not be somewhat higher? My answer is: indeed it should. If not, a society stagnates and decays into colorless skepticism or, worse, into defeatism. I refer once more to the Bible in which the standards are very high—for many of us, perhaps unattainably high. Does it harm to consider that high level as a guideline? Certainly not, it is virtuous. It spurs us to try to reform or better a society, with the ultimate (although unattainable) goal of perfection. It provides life with purpose and meaning, however modest the improvement may ultimately be. Such objectives feed hope, and hope is the priceless fruit of the Messianic notion. Without hope, living would make little sense.

As a motto for a scientific movement, Protagoras’s adage seems unsuitable; as a motto for the human condition—disheartening. Man too often remains below par, to serve as a measure of all things.

Descartes: more right than wrong

Videtur quod sic. It would appear that in psychiatry the soul has to retreat in favor of the brain, that Cartesian dualism is false, that a truly causal treatment in psychiatry is treatment of a brain disorder. That viewpoint is misleading and counterproductive, in terms of both patient care and scientific progress.

Brain and mind are of equal status; communicating partners. They are unbreakably linked but made of fundamentally different “stuff.” Much can be achieved with technology. However, technology fails in understanding the mind. Man is more than a machine—he has spirit, will, and self-determination, all of which are impenetrable to biological technology.

Body and soul—brain and mind: two complex worlds mutually dependent and yet in many ways self-governing. Human nature truly is a natural wonder. It is not surprising that it is imagined (and believed by some) to be created in the image of God.

References

1. Damasio AR. Descartes’ Error: Emotion, Reason, and the Human Brain. New York: GP Putnam’s Sons; 1994.
2. Kendler KS. Toward a philosophical structure for psychiatry. Am J Psychiatry. 2005;162:433-440.
3. Swaab DF. Evolutionair gezien zijn we weinig meer dan wegwerpartikelen [evolutionarily seen, we are no more than throw away commodities]. In: Visser H, ed. Leven zonder God. Amsterdam: Uitgeverij LJ van Veen; 2003.
4. Kandel ER. A new intellectual framework for psychiatry. Am J Psychiatry. 1998;155:457-469.
5. Guze SB. Biological psychiatry: is there any other kind? Psychol Med. 1989;19:315-323.
6. van Praag HM. Seat of the divine: a biological “proof of God’s existence”? Verhagen PJ, van Praag HM, López-Ibor JJ Jr, et al, eds. Religion and Psychiatry: Beyond Boundaries. Chichester, West Sussex, UK: John Wiley & Sons; 2010:523-540.
7. Swaab DF. Wij Zijn Ons Brein [We Are Our Brains]. Amsterdam: Uitgeverij Contact; 2010.
8. Wolters G. Gedragscontrole. Vrije wil of neuronale processen [Behavioral regulation: free will or neuronal processes]. De Psycholog. 2005;24:23-29.
9. Genesis 2:7.

Psychiatric Times This article originally appeared on:

APA Reference
Martin, L. (2012). Neuroscientific Mirages: Are We No More Than Our Brains?. Psych Central. Retrieved on September 26, 2012, from http://pro.psychcentral.com/2012/neuroscientific-mirages-are-we-no-more-than-our-brains/001049.html


Last reviewed: By John M. Grohol, Psy.D. on 18 Sep 2012


Posted by: AT 11:31 am   |  Permalink   |  Email
Tuesday, September 25 2012


September 24, 2012

A Call for Caution on Antipsychotic Drugs

You will never guess what the fifth and sixth best-selling prescription drugs are in the United States, so I’ll just tell you: Abilify and Seroquel, two powerful antipsychotics. In 2011 alone, they and other antipsychotic drugs were prescribed to 3.1 million Americans at a cost of $18.2 billion, a 13 percent increase over the previous year, according to the market research firm IMS Health.

Those drugs are used to treat such serious psychiatric disorders as schizophrenia, bipolar disorder and severe major depression. But the rates of these disorders have been stable in the adult population for years. So how did these and other antipsychotics get to be so popular?

Antipsychotic drugs have been around for a long time, but until recently they were not widely used. Thorazine, the first real antipsychotic, was synthesized in the 1950s; not just sedating, it also targeted the core symptoms of schizophrenia, like hallucinations and delusions. Later, it was discovered that antipsychotic drugs also had powerful mood-stabilizing effects, so they were used to treat bipolar disorder, too.

Then, starting in 1993, came the so-called atypical antipsychotic drugs like Risperdal, Zyprexa, Seroquel, Geodon and Abilify. Today there are 10 of these drugs on the market, and they have generally fewer neurological side effects than the first-generation drugs.

Originally experts believed the new drugs were more effective than the older antipsychotics against such symptoms of schizophrenia as apathy, social withdrawal and cognitive deficits. But several recent large randomized studies, like the landmark Catie trial, failed to show that the new antipsychotics were any more effective or better tolerated than the older drugs.

This news was surprising to many psychiatrists — and obviously very disappointing to the drug companies.

It was also soon discovered that the second-generation antipsychotic drugs had serious side effects of their own, namely a risk of increased blood sugar, elevated lipids and cholesterol, and weight gain. They can also cause a potentially irreversible movement disorder called tardive dyskinesia, though the risk is thought to be significantly lower than with the older antipsychotic drugs.

Nonetheless, there has been a vast expansion in the use of these second-generation antipsychotic drugs in patients of all ages, particularly young people. Until recently, these drugs were used to treat a few serious psychiatric disorders. But now, unbelievably, these powerful medications are prescribed for conditions as varied as very mild mood disorders, everyday anxiety, insomnia and even mild emotional discomfort.

The number of annual prescriptions for atypical antipsychotics rose to 54 million in 2011 from 28 million in 2001, an 93 percent increase, according to IMS Health. One study found that the use of these drugs for indications without federal approval more than doubled from 1995 to 2008.

The original target population for these drugs, patients with schizophrenia and bipolar disorder, is actually quite small: The lifetime prevalence of schizophrenia is 1 percent, and that of bipolar disorder is around 1.5 percent. Drug companies have had a powerful economic incentive to explore other psychiatric uses and target populations for the newer antipsychotic drugs.

The companies initiated dozens of clinical trials to test these drugs against depression and, more recently, anxiety disorders. Starting in 2003, the makers of several second-generation antipsychotics (also known as atypical neuroleptics) have received F.D.A. approval for the use of these drugs in combination with antidepressants to treat severe depression, which they trumpeted in aggressive direct-to-consumer advertising campaigns.

The combined spending on print and digital media advertising for these new antipsychotic drugs increased to $2.4 billion in 2010, up from $1.3 billion in 2007, according to Kantar Media. Between 2007 and 2011, more than 98 percent of all advertising on atypical antipsychotics was spent on just two drugs: Abilify and Seroquel, the current best sellers.

There is little in these alluring advertisements to indicate that these are not simple antidepressants but powerful antipsychotics. A depressed female cartoon character says that before she starting taking Abilify, she was taking an antidepressant but still feeling down. Then, she says, her doctor suggested adding Abilify to her antidepressant, and, voilà, the gloom lifted.

The ad omits critical facts about depression that consumers would surely want to know. If a patient has not gotten better on an antidepressant, for instance, just taking it for a longer time or taking a higher dose could be very effective. There is also very strong evidence that adding a second antidepressant from a different chemical class is an effective and cheaper strategy — without having to resort to antipsychotic medication.

A more recent and worrisome trend is the use of atypical antipsychotic drugs — many of which are acutely sedating and calming — to treat various forms of anxiety, like generalized anxiety disorder and even situational anxiety. A study last year found that 21.3 percent of visits to a psychiatrist for treatment of an anxiety disorder in 2007 resulted in a prescription for an antipsychotic, up from 10.6 percent in 1996. This is a disturbing finding in light of the fact that the data for the safety and efficacy of antipsychotic drugs in treating anxiety disorders is weak, to say nothing of the mountain of evidence that generalized anxiety disorder can be effectively treated with safer — and cheaper — drugs like S.S.R.I. antidepressants.

There are a small number of controlled clinical trials of antipsychotic drugs in generalized anxiety or social anxiety that have shown either no effect or inconsistent results. As a consequence, there is no F.D.A.-approved use of an atypical antipsychotic for any anxiety disorder.

Yet I and many of my colleagues have seen dozens of patients with nothing more than everyday anxiety or insomnia who were given prescriptions for antipsychotic medications. Few of these patients were aware of the potential long-term risks of these drugs.

The increasing use of atypical antipsychotics by physicians to treat anxiety suggests that doctors view these medications as safer alternatives to the potentially habit-forming anti-anxiety benzodiazepines like Valium and Klonopin. And since antipsychotics have rapid effects, clinicians may prefer them to first-line treatments like S.S.R.I. antidepressants, which can take several weeks to work.

Of course, physicians frequently use medications off label, and there is sometimes solid empirical evidence to support this practice. But presently there is little evidence that atypical antipsychotic drugs are effective outside of a small number of serious psychiatric disorders, namely schizophrenia, bipolar disorder and treatment-resistant depression.

Let’s be clear: The new atypical antipsychotic drugs are effective and safe. But even if these drugs prove effective for a variety of new psychiatric illnesses, there is still good reason for caution. Because they have potentially serious adverse effects, atypical antipsychotic drugs should be used when currently available treatments — with typically fewer side effects and lower costs — have failed.

Atypical antipsychotics can be lifesaving for people who have schizophrenia, bipolar disorder or severe depression. But patients should think twice — and then some — before using these drugs to deal with the low-grade unhappiness, anxiety and insomnia that comes with modern life.

Dr. Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College in Manhattan.


Posted by: AT 09:06 am   |  Permalink   |  Email
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